Working with the alcohol industry on alcohol policy: should we sometimes sit at the same table?

The prompt for this editorial is the recent report by Peter Anderson & Ben Baumberg [1], describing results of a survey of stakeholders' views of alcohol policy in Europe. This report is a companion document to a recent major review, Alcohol in Europe, by the same authors [2]. The main focus is a survey of stakeholders on an array of different alcohol policy questions and strategies: (i) alcohol industry representatives (AIs, n = 30, no refusals); (ii) representatives of government organizations (GOs, n = 23, seven non-responses); and (iii) representatives of non-government organizations (NGOs, n = 22, eight non-responses). Interesting and detailed results are presented on some 35 specific questions with categorical responses as well as thematic analysis of responses to several open-ended questions on policy implementation, barriers and perceived effectiveness. Three important, if predictable, differences are identified between the AIs and the rest: they were significantly less likely to endorse regulatory strategies (such as higher taxes, health warning labels, lower permitted blood alcohol levels for drivers), they were more likely to endorse educational strategies and more likely to believe that the alcohol industry should be a partner in making policy on alcohol in public health. All groups agreed that certain measures should be implemented more widely: (1) enforcement of existing drink-driving and liquor laws; (2) counselling for family members of people with alcohol problems; and (3) ‘interventions to reduce hazardous and harmful alcohol consumption’. A preliminary question when evaluating the significance of this report must be: how representative are these relatively small groups of stakeholders who participated in the study? Who exactly are they and how were they selected? In the first place, members of the group of government officials each presumably represent the government of their country in their capacity as members of the European Commission's Alcohol and Health Working Group. (They are described rather neutrally as ‘country counterparts’.) The NGOs had national or Europe-wide responsibilities that included alcohol policy and were selected as members of an Alcohol Policy Network, a project financed partly by the European Commission. Next, the alcohol industry stakeholders are also described as ‘stakeholders of the European Commission’s Alcohol and Health Working Group', presumably having different status to the country counterparts as a group to be consulted about alcohol and health matters as opposed to full members of the Working Group. Thus, each group of stakeholders was clearly representing their constituency in high-level policy discussions between governments, national agencies and major drinks industry groups. Their attitudes and beliefs on alcohol policy are therefore clearly of some significance and worthy of formal analysis. I have been privileged to be part of national policy-making processes in two countries (Australia and Canada) and have participated to a limited degree in European alcohol policy processes. The essential dynamics revealed in this report between public health and alcohol industry stakeholders will be familiar to anyone who has participated in such processes: (i) the public health sector prefers more evidence-based regulatory strategies while the industry stakeholders prefer softer, educational strategies with a much weaker evidence base; (ii) the public health sector would really prefer the industry groups not to be present and see them as a barrier to policy-making, while the industry representatives see their involvement and ‘partnership’ with government as essential. If I have one small criticism of the report it is that it deals with the ‘alcohol industry’ as if it was a homogeneous entity with a common set of interests at the policy table. My experience has been that while there are some common threads and core interests, there are also some substantial divergences that are important to consider. For example, the manufacturers of distilled spirits tend to believe fervently that their product should be taxed at the same rate as beer per unit of alcohol, a view not usually shared by brewers. The representatives of major retail groups may favour limits on alcohol outlet density as a means of restricting competition, whereas manufacturers will tend to oppose such restrictions as being likely to reduce overall sales. It may also be that government alcohol monopolies were represented in the AI group, which would bring yet another different perspective to bear with perhaps concerns about the need for protecting government revenues. Such different vested interests may explain why the alcohol industry informants are virtually unanimous in their ratings of the effectiveness and their support for most strategies, buthave mixed positions regarding the questions ‘taxes should be proportional to the alcohol content’ of beverages and whether ‘impact assessments of the health and social environment’ should be conducted before considering the issue of a new liquor licence. The latter would tend to slow down the issue of new licences and might be more favoured by established retail groups. These niceties aside, in a perhaps deliberately understated way, the Anderson & Baumberg [1] report highlights a fundamental dilemma in national and international alcohol policy making: when, if ever, is it appropriate to involve commercial vested interests? Stakeholder groups themselves are predictably discordant in their views on this. This fundamental question comes into starkest relief when alcohol taxation is discussed. Review after international review identifies pricing and taxation strategies as having the strongest evidence base of any alcohol policy options available to government [3–5]. Higher taxes will always be opposed by any manufacturing and/or retail group in relation to their product as they threaten the profits that can be returned to shareholders. However, national alcohol policy-making in practice often involves and includes alcohol industry representatives [e.g. 6]. My experience in Australia and Canada has been that some limited agreement is possible to provide incentives for the manufacture, sale and consumption of lower alcohol strength, whether by tax or price reductions. However, agreement to even peg taxation rates with inflation, let alone make any slight increase, is completely out of the question in this situation and hence the most effective strategies are filtered out of formal advice to government. In Anderson & Baumberg's [1] analysis of European stakeholders, the AIs uniformly opposed linking tax rates to inflation or increasing taxes to a minimum across the European Union. However, a third of the AIs supported the idea of making taxes proportional to alcohol content of drinks. In my experience, unusual circumstances and reassurances are required even to obtain an agreement to achieve this in practice, involving (i) no overall increase in taxation revenue and (ii) no advantage being gained by one major beverage manufacturing group over another [7]. Such agreements are, however, of potentially major significance even if they fall short of the ideal. Less than 1% of beer sold in Canada has a strength of less than 4% [8], whereas in Australia up to 40% of the beer market by value consists drinks with a lower alcohol content than 3.8% [7]. Canada has no tax incentives for the consumption and sale of lower strength beers, whereas Australia has three bands of excise tax rates for beer graduated according to alcoholic strength, i.e. less alcohol equals lower tax rate [8]. It should be noted in all this that, regardless of any of the stakeholder views in this study, it is usually Finance and Treasury departments that determine alcohol tax policies usually with scant regard for public health concerns [8]. The main point here is that significant progress can be made on some issues with the alcohol industry as partners in the policy-making process even on the apparently infertile ground of alcohol tax reform. On the other issues, however, progress by consensus is completely impossible. Such basic and proven strategies as linking tax rates to inflation or introducing even small tax increases to provide extra funds for the prevention and treatment programmes [9] can only be introduced over the wishes of alcohol industry stakeholders. The important lesson here is the necessity of being completely clear as to when it is and when it is not appropriate to have commercial vested interest groups at the policy table determining what is in the public interest. If a counterbalance is needed against the possibility of overzealous public health officials over-regulating the availability of our favourite recreational drug, it is surely through the means of first informing and then testing community opinion. Sectors of the alcohol industry do need to be consulted in such a process and can also contribute usefully to the implementation of some strategies. For example, the Australian Hotels Association assisted with the distribution of information about Australian low-risk drinking guidelines in bars, using posters and beer mats to convey a range of messages approved by the National Health and Medical Research Council [10]. However, as Anderson & Baumberg [1] demonstrate in their report, on core regulatory matters such as overall level of taxation and availability, involvement of the industry will usually result in the filtering out of those policies with the strongest evidence. Room [11] has shown how in recent years the United Kingdom is a case study in what can go wrong when the alcohol industry is involved in shaping every aspect of national policy. In summary, I suggest that in some aspects of alcohol prevention and policy implementation it can be useful to engage with the alcohol industry and work in partnership. I have argued elsewhere that this has to be limited to ‘harm reduction’ strategies that do not require any reduction in alcohol use for their effectiveness (e.g. use of plastic glassware at high risk venues for violence) and to some ‘demand reduction’ strategies that seek to educate about low-risk alcohol use [5,12]. In relation to ‘supply reduction’ strategies that go directly against the interests of all sectors of the alcohol industry, in an ideal world policy-making would take note of only the scientific evidence, on one hand, and community opinion on the other hand.

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